Healthcare Provider Details

I. General information

NPI: 1346722055
Provider Name (Legal Business Name): SHOAL CREEK FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 32ND ST STE 102
JOPLIN MO
64804-1528
US

IV. Provider business mailing address

PO BOX 4427
JOPLIN MO
64803-4427
US

V. Phone/Fax

Practice location:
  • Phone: 417-622-0648
  • Fax: 417-622-0497
Mailing address:
  • Phone: 417-622-0648
  • Fax: 417-622-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2018010120
License Number StateMO

VIII. Authorized Official

Name: DR. SHELLY DIANE SEDBERRY
Title or Position: OWNER/PRESIDENT
Credential: DPM
Phone: 417-622-0648